Test Bank for Medical-Surgical Nursing exam with 300 verified questions with answers lates | Exams Nursing | Docsity (2024)

Download Test Bank for Medical-Surgical Nursing exam with 300 verified questions with answers lates and more Exams Nursing in PDF only on Docsity! Test Bank for Medical-Surgical Nursing exam with 300 verified questions with answers latest update A patient with mitral valve disease is admitted to a medical unit with fever, chills, SOB, malaise and a newly developed cardiac murmur. Based on the patient's new diagnosis of endocarditis, the nurse will begin preparing him for discharge by teaching about: a. lifestyle modifications. b. warfarin (Coumadin) therapy. c. self-administration of IV antibiotics. d. the need for fluid restrictions. --correct answer--c. self-administration of IV antibiotics. A patient with hypercholesterolemia was prescribed pravastatin (Prevachol). The nurse should teach the patent about which of the following side effects for this medication? a. Muscle weakness b. Flushing c. Itching d. Hypotension --correct answer--a. Muscle weakness Ms. Parsons, age 65, is transferred to a medical telemetry unit after several days in the coronary care unit for treatment of an acute MI. Ms. Parsons remains very anxious, with occasional episodes of chest pressure. Which medication does the nurse prepare for Ms. Parsons to decrease her anxiety and improve cardiac output? a. Nitroprusside (Nipride) b. Diazepam (Valium) c. Morphine sulfate (MS) d. Dopamine (Intropin) --correct answer--c. Morphine sulfate (MS) The nurse's assessment of Mr. Harrison's response to digoxin will include which of the following as the most common early indicator of toxicity. a. Anorexia b. Diarrhea c. Headache d. Confusion --correct answer--a. Anorexia The nurse is also aware that some of Mr. Harrison's medications can increase serum digitalis concentrations and thus the risk for digoxin toxicity. These include: a. calcium carbonate (Tums) b. cholestyramine (Questran) c. sulfasalazine (Azulfidine) d. amiodarone (Cordarone) --correct answer--d. amiodarone (Cordarone) The nurse teaches Ms. Pratt about the use of nitroglycerin. Following teaching, it is most important for the patient to: a. indicate she will call for help if three nitroglycerin tablets don not relieve her chest pain. b. identify flushing and dizziness as common side effects of the drug. c. verbalize understanding that nitroglycerin will help prevent her from having a myocardial infarction (MI) d. confirm she will not take the drug unless she is experiencing chest pain. - -correct answer--a. indicate she will call for help if three nitroglycerin tablets don not relieve her chest pain. A 68 year old female is admitted with a diagnosis of heart failure and ischemic cardiomyopathy. Her cardiac history includes three previous MIs and three coronary artery bypass grafts. The patient's appetite is unchanged. Which dietary restriction would be the highest priority for this patient? The nurse is caring for multiple patients with a diagnosis of coronary artery disease. The identifies which of the following as at the greatest risk for early onset of the disease? a. Hispanic male b. Asian female c. African-American female d. Caucasian male --correct answer--c. African-American female A patient with rheumatic fever has been told the infection could reoccur. The nurse teaches the patient to seek medical attention for which of the following symptoms that suggest reinfection? a. Shortness of breath at rest b. Unexplained weight loss c. Excessive fatigue d. lower-extremity ecchymosis --correct answer--c. Excessive fatigue A patient is seen at the clinic for a routine physical examination. After the patient is assessed for evidence of peripheral vascular disease, the nurse explains that which of the following tests is typically used to assist in the diagnosis? 1. Allen's Test 2. Ankle brachial pressure index. 3. Cardiac Stress Test. 4. Echocardiogram --correct answer--2. Ankle brachial pressure index. Rationale: The ankle brachial index (ABI) is the blood pressure ratio between the lower legs and the arms. Blood pressure in the legs is normally higher than the arms, and abnormalities indicate narrowing of the arteries. Clinical findings that may suggest the presence of PVD includes a history of angina with activity, intermittent claudication, and abnormal (weak or absent) pedal pulses. The formula for ABI is the systolic blood pressure of the ankle (measured at the dorsalis pedis or posterior tibial arteries) divided by the systolic pressure in the arms. It is measured on both sides. A ratio of 1.0 indicates peripheral vascular disease. Incorrect: Allen's test is used to assess blood supply to the hand.Incorrect: Cardiac stress tests are used to measure the heart's ability to respond to stress. Incorrect: ECG evaluates the structure and function of the heart muscle, but does not tell if there is peripheral vascular disease present. A patient has been diagnosed with left-sided congestive heart failure, and is confused about the return of oxygenated blood from the lungs. To clarify the confusion, the nurse explains all chambers of the heart dealing with blood circulation. The nurse is correct when she tells the client: 1. A muscular space called the pericardial space separates the chambers of the right side from the left side. 2. Blood flows into the left ventricle which pumps it out against high resistance into the systemic circulation. 3. The blood moves to the left ventricle, which pumps blood into the lungs. 3. The heart consists of 5 chambers. 4. The left atrium receives oxygenated blood from the lungs. 5. The right atrium receives deoxygenated blood from the body tissues. -- correct answer--2. Blood flows into the left ventricle which pumps it out against high resistance into the systemic circulation. 3. The blood moves to the left ventricle, which pumps blood into the lungs. 4. The left atrium receives oxygenated blood from the lungs. 5. The right atrium receives deoxygenated blood from the body tissues. Rationale: Heart consists of 4 chambers: 2 atria and 2 ventricles. The right and left chambers are separated down the middle of the heart by a septum, like a wall. The right atrium receives deoxygenated from the body, and the blood then moves down into the right ventricle, which pumps it to the lungs with low resistance. The left atrium then receives oxygenated blood from the lungs, and that blood moves down into the left ventricle. The left ventricle, which is the most muscular chamber, pumps oxygen rich blood into the systemic circulation. A patient recovering from a MI has been in bed for 6 days. The patient now complains of calf pain. The nurse should first: 1. Administer pain medication as ordered. 2. Assess the calf for redness warmth and swelling. 3. Massage the calf to relieve the muscle cramp. Observe the patient walking. --correct answer--2. Assess the calf for redness warmth and swelling. Rationale: Due to the time spend in bed and inactive, the patient is at high risk for the development of a DVT. Pain in the calf, redness or heat, and swelling in the affected extremity are signs of a DVT. Diagnostic tests that help diagnose a DVT include a D-dimer test to confirm the presence of fibrin degradation in products from a clot, venous ultrasound, venography to visualize the clot with contrast, or less commonly MRI or CT. The nurse is caring for a patient in the early stages of heart failure. The family is curious as to how the body adapts to heart failure. The nurse knows that during the early stages of heart failure, which specific compensatory mechanisms occur? 1. Decreased cardiac output inhibits the release of ADH by the pituitary gland. 2. Hypotension stimulates the baroreceptors to increase sympathetic activity. 3. Hypotension stimulates the baroreceptors to decrease sympathetic activity. used to treat hypertension. Dyspnea during activity is NOT associated with hypertension. Dyspnea can be a sign of low cardiac output (congestive heart failure), pulmonary edema, severe anemia, or a respiratory problem (asthma, pneumonia, etc.). ;./ The nurse is evaluating a 52 year old male for risk factors for CAD. The patient is overweight, male, and smokes a pack a day. The nurse questions the patient about other risk factors including: 1) A history of atherosclerotic heart disease. 2) A history of diabetes. 3) A history of gout. 4) Elevated HDL levels. --correct answer--2) A history of diabetes. Rationale: The major risk factors for CAD are diabetes, smoking, increased LDL levels, and hypertension. Elevated HDL levels are PROTECTIVE against CAD. Atherosclerotic heart disease is just another name for coronary heart disease. Gout is not associated with CAD. The nurse is knowledgeable about sinoatrial node dysrhythmias if she selects which of the following causes of sinus tachycardia? Select all that apply. 1. Emotional and physical stress 2. Fever 3. Heart Failure 4. Increased Intracranial pressure 5. Infection 6. MI --correct answer--1. Emotional and physical stress 2. Fever 3. Heart Failure 5. Infection Rationale: Sinus tachycardia is defined as sinus rhythm with a rate greater than 100 beats per minute. Causes of ST include: fever, emotional & physical stress, heart failure, fluid volume loss, hyperthyroidism, hypercalcemia, caffeine, nicotine, exercise, and some medications. In the vast majority of cases, sinus tachycardia results from some underlying condition such as exercise, infection, or congestive heart failure, which alters the autonomic nervous system. Sinus bradycardia may result from the following: Valsalva's maneuver, drugs like digitalis, MI, hyperkalemia, hypothyroidism, severe hypoxia, and increased ICP. The nurse is auscultating the heart of a patient with congestive heart failure. The nurse hears an extra sound with a very low pitch, immediately after the 2nd heart sound S2. The nurse interprets this as: 1. A murmur due to an aortic regurgitation. 2. A split S1. 3. A split S2. 4. A third heart sound (S3). --correct answer--Rationale: S3 occurs immediately after S2. It has a very low pitch and has been described as a "gallop" or vibration. It can occur normally in people under 40 and in athletes. Later in life, it may indicate heart failure (ventricular dysfunction) and/or fluid overload. An ICU nurse is providing continuing health education to new nurses in the unit. Which statements made by the nurse are correct? 1. Dysrhythmias can decrease the heart's ability to pump effectively but cannot cause death. 2. Dysrhythmias result from disturbances in the automaticity, conduction, and re-entry of impulses. 3. If the SA node fails to fire, in a normal heart, the AV node should take over the pacemaker function. 4. Normal sinus rhythm is the usual heart rhythm is the usual heart rhythm, beginning in the AV node. 5. The most serious complication of a dysrhythmia is MI. 6. The SA node is the pacemaker of the heart. --correct answer--1. Dysrhythmias result from disturbances in the automaticity, conduction, and re-entry of impulses. 2. If the SA node fails to fire, in a normal heart, the AV node should take over the pacemaker function. 5. The SA node is the pacemaker of the heart. Rationale: The SA node is the pacemaker of the heart because it possesses the highest level of automaticity.The SA node is regulated by the nervous system through the vagus nerve. If it fails to fire, the AV node should take over pacemaker function. Dysrhythmias can severely decrease the heart's ability to pump effectively even causing death. Dysrhythmias can occur when there are disturbances from the three mechanisms of the heart: automaticity, conduction, and re-entry of impulses. The most serious complication of dysrhythmias is not MI. The most serious complication of a dysrhythmia is sudden death. A client has been admitted to the unit for treatment of dehydration. During the initial meeting of the client and the nurse, which nursing action is most appropriate? 1. Evaluate the client's response to treatment thus far. 2. Establish the outcomes of hospitalization for the client. 3. Tell the client that the provider will explain what to expect in the hospital. 4. Determine the preliminary client needs upon discharge. --correct answer-- 4. Determine the preliminary client needs upon discharge. indicate brain, myocardial, or skeletal damage. Myoglobin would be increased in AMI, not decreased, but this is a nonspecific finding because myoglobin refers to only muscle tissue. The nurse is caring for a client diagnosed with acute renal failure. Which numeric values best represent this client's anticipated arterial blood gas results? 1. pH 7.48, pCO2 37, HCO3 29. 2. pH 7.34, pCO2 49, HCO3 23. 3. pH 7.27, pCO2 38, HCO3 19. 4. pH 7.46, pCO2 30, HCO3 25. --correct answer--3. pH 7.27, pCO2 38, HCO3 19. Rationale: Clients in acute renal failure have an accumulation of uric acid in the blood that makes them acidotic; and thus the acidosis is of metabolic origin. The bicarbonate level is low because it is used to trying to neutralize body acid. A low pH (7.35-7.45) would indicate an acidosis, while a high pH indicates alkolosis. An elevated bicarbonate level (22-26) indicates a metabolic cause for alkolosis. The nurse is caring for a client newly diagnosed with renal failure. What serum laboratory value should the nurse use as the most specific indicator of the effectiveness of the treatment? 1. Potassium level 5.0. 2. Blood urea nitrogen BUN 40. 3. Creatinine level 4. Urine specific gravity 1.010 --correct answer--3. Creatinine level Rationale: Creatinine levels (0.8-1.6) are more sensitive and specific for renal function than BUN (normal 8-22). Although the BUN is used to assess renal function, it can also be affected by diet and fluid status and is therefore not the most specific indicator available. The potassium level can be affected by many factors as well, such as tissue damage and adrenal insufficiency; however, this level is normal range (3.5-5.1). Which factor should the nurse consider when assessing the medication needs of a client with type 1 diabetes mellitus who is being admitted to the nursing unit? Select all that apply: 1) The client's exercise pattern 2) The client's acute illness condition. 3) Nutritional status of the client 4) The length of time the client has been diagnosed with diabetes. 5) Allergies previously reported. --correct answer--1) The client's exercise pattern 2) The client's acute illness condition. 3) Nutritional status of the client Rationale: A balance between glucose and insulin is needed to maintain homeostasis and stabilize diabetes. Exercise, acute illness, and nutrition are all instrumental in assessment and determining medication need status. Length of time since diagnosis may give some information as to self management but is not specific to medication therapy. Allergies that were previously reported are not specific to insulin therapy, especially since the development of human insulin using recombinant DNA technology. The nurse is caring for a client in the short procedure unit (SPU) following a bronchoscopy using moderate (conscious) sedation. Prior to discharging the client, the nurse verifies that the client has achieved which priority outcome? 1. Verbalizes symptoms of late complications. 2. Demonstrates an intact gag reflex. 3. Remains afebrile for up to 2 postop days. 4. Reports being thirsty and asks for oral fluids. --correct answer--2. Demonstrates an intact gag reflex. Rationale: In intact gag reflex indicates that the topical sedation has lost its effect and the client is able to swallow (a major safety consideration prior to discharging the client from the health care facility). The ability to swallow precedes consumption of oral intake and coincides with the return of the cough and gag reflex. Knowing symptoms to report to the The nurse is caring for a 68 year old client who is scheduled for discharge later that day. An ABG done the previous morning reveal a PaO2 of 87. The client has a respiratory rate of 22 and clear lungs, and reports no shortness of breath. What should be the nurse's response? 1. Call the health care provider to report the PaO2. 2. Monitor the client more closely because a physiological abnormality is beginning. 3. Do nothing because a PaO2 of 87 is normal in an older adult. 4. Call the family to tell them to anticipate that the discharge will be canceled. --correct answer--3. Do nothing because a PaO2 of 87 is normal in an older adult. Rationale: The PaO2 normally drops as the individual ages and can be as low as 83 in a 90-year-old (adult normal 80 to 100). The client's assessment is normal. Since the client reports no distress, there is no reason to call the health care provider for a normal for a normal finding. There is no need to anticipate an untoward event or anticipate canceling discharge. The nurse is caring for a client diagnosed with right middle lobe pneumonia. The nurse should perform which intervention to mobilize secretions? 1. Administer antibiotics as ordered. 2. Limit fluids to IV only. The nurse is assessing a patient with asthma exacerbation for signs of worsening disease. Which of the following would indicate that the patient's asthma exacerbation is worsening? 1. Diminished breath sounds 2. Expiratory and inspiratory wheezes. 3. Less than 80% of predicted forced expiratory volume. 4. Loud wheezes. --correct answer--1. Diminished breath sounds Rationale: Breath sounds that become increasingly diminished indicates that a severe obstruction is present and risk of respiratory failure is high. Wheezes can occur during all asthma exacerbation, regardless of severity. Less than 80% of predicted forced expiratory volume is indicative of moderate-to-severe asthma, but this information does not indicate worsening exacerbation. The nursing diagnosis for a patient with pneumonia is ineffective airway clearance r/t increased suptum production. Which is an appropriate goal for this patient? 1. The patient will maintain a patent airway AEB the absence of dyspnea. 2. The patient will maintain an open airway AEB no complaints of pain. 3. The patient will maintain an open airway AEB by tachypnea. 4. The patient's airway will remain free of obstruction. --correct answer--1. The patient will maintain a patent airway AEB the absence of dyspnea. Rationale: The absence of dyspnea will indicate whether the patient's goal of maintaining a patient airway is met. A patient with pneumonia may have increased secretions that can lead to ineffective airway clearance. Assessment findings that indicate that the patient is effectively clearing his airway indicate that the patient is effectively clearing his airway include the absence of dyspnea, improvement of lung sounds, and normal skin color. Tachypnea would indicate the patient has continued ineffective airway clearance. Complaints of pain are NOT an effective measure of airway clearance. The third option does not have a measurement for the goal. A patient is admitted to the hospital for a pulmonary embolism. The nurse assesses the patient knowing that which of the following is commonly reported? Select all that apply. Select all that apply. 1. Anxiety 2. Hemoptysis 3. New dyspnea on exertion or rest. 4. Slow progressing dyspnea 5. Sudden chest pain 6. Sudden headache --correct answer--1. Anxiety 2. Hemoptysis 3. New dyspnea on exertion or rest. 5. Sudden chest pain Rationale: Sudden chest pain is the most common initial symptom reported. Other symptoms include dyspnea, increased respiratory rate, blood tinged suptum, tachycardia, anxiety, fever, and diaphoresis. Dyspnea can occur at rest or with exertion, and has a sudden onset. Headaches are not a common sign of a pulmonary embolism. The nurse is informing a patient about postural drainage. To facilitate clearing of the lungs, the nurse should position the patient based on which assessment? 1. Auscultation 2. Inspection of chest 3. Percussion of thorax 4. X-ray --correct answer--1. Auscultation Rationale: Auscultation will help the nurse determine which areas of the lung need draining and which position is most appropriate. Percussion may give the nurse clues to which areas need draining, but auscultation is more accurate. Inspection and a chest x-ray will not help the nurse in this situation. A client is admitted to the medical department due to pneumonia associated with influenza. Which of the following interventions promotes airway patency? Select all that apply. 1. Apply chest physiotherapy 2. Frequent Turning 3. Increase fluid intake 4. Provide a quiet environment 5. Schedule activities after treatments. 6. Teach client to avoid stress. --correct answer--1. Apply chest physiotherapy 2. Frequent Turning 3. Increase fluid intake Rationale: Increasing fluid intake will facilitate easy expectoration of mucus secretions that accumulate in the airway. Frequent turning promotes airway patency. Clients with altered level of consciousness should be turned at least ever 2 hours and should be placed in side-lying positions to prevent aspiration, unless contraindicated. Applying chest physiotherapy is an aggressive measure to maintain airway patency and may be required by certain conditions. This usually requires a doctor's order. Examples of Chronic Illnesses --correct answer---Congestive Heart Failure (CHF) -Diabetes Mellitus (DM) -Chronic Obstructive Pulmonary Disease (COPD) -Arthritis -Lupus -Chronic illnesses are the leading cause of health problems in the world Characteristics of a Chronic Illness --correct answer---It is a permanent change -It causes, or is caused by irreversible alterations in normal anatomy and physiology. -It requires special patient education for rehabilitation. -It usually requires a long period of care or support. -Increases health care costs; prolongs hospitalization. -Increases assistance; taxes family's coping. Which statements made by the nurse while taking a nursing history would elicit the greatest amount of client data? 1. Did your pain begin recently? 2. You said the pain started yesterday? 3. Can you tell me more about how the pain began? 4. The pain isn't bad right now is it? --correct answer--3. Can you tell me more about how the pain began? Rationale: Open-ended questions encourage the client to speak freely and to elaborate and clarify answers as needed. Restrictive questions that only require a "yes" or a "no" answer do not encourage free exchange of information nor does frequent rephrasing of the client's answer. Leading questions tend to elicit A nurse is revising the client goals and interventions in the nursing care plan. What information enables the nurse to make relevant revisions? 1. Knowledge of the hospital's standards of care. 2. Medical assessment and written prescriptions. 3. Health care team conferences. 4. Validation of the effectiveness of nursing interventions. --correct answer- -4. Validation of the effectiveness of nursing interventions. Rationale: It is necessary to know how well the interventions worked in order to revise them appropriately. Medical assessment and written prescriptions are components of the client care but not the focus of the nursing plan of care. The focus of the care plan is to direct the nurse to where the client is in his or her recovery, where he needs to go next, and what the nurse and client need to do to achieve that goal. The nurse would assess for hyperkalemia in a client with which of the following problems? 1. Renal failure. 2. Nausea and vomiting. 3. Excessive laxative use. 4. Loop diuretic use. --correct answer--1. Renal Failure Rationale: Renal failure results in the inability of the kidneys to excrete potassium, which leads to hyperkalemia. Nausea, vomiting, excessive laxative use, and loop diuretic all cause excess fluid loss from the body. With this fluid will also be loss of electrolytes which would lead to hypokalemia rather than hypokalemia. A nurse has been assigned the following clients on the day shift. In updating their plans of care, which client would have both Risk for Ineffective Breathing Pattern and Risk for Impaired Gas Exchange as a priority diagnoses? 1. A newly admitted 32-year-old female with exacerbation of myasthenia gravis. 2. A second day post-op 66 year old client who underwent femoropopliteal bypass grafting. 3. A 56 year old client admitted for an appendectomy. 4. An 82 year old client with non-metastic prostate cancer. --correct answer- -1. A newly admitted 32-year-old female with exacerbation of myasthenia gravis. Rationale: A client with myasthenia gravis may have risk for ineffective breathing pattern because of neuromuscular effects of a disease, and may also have risk for impaired gas exchange because of the possible respiratory impairments from the physiological process of this disease. A postoperative client who had surgery more than 24 hours ago may have pain at the surgical site but should not have hypoventilation from anesthesia, as these effects should wear off within 24 hours. A preoperative client in pain may or may not have respiration affected. It is highly unlikely that a client with prostate cancer will experience respiratory difficulty unless there is dysuria or localized pain, which may result in change in breathing pattern. The nurse is caring for a client on digoxin. Which electrolyte abnormality should the nurse be concerned about regarding the risk of digoxin toxicity? 1. Sodium 132 mEq/L 2. Potassium 3.0 mEq/L 3. Magnesium 1.0 mEq/L 4. Calcium 9.2 mEq/L --correct answer--2. Potassium 3.0 mEq/L Symptomatic respiratory distress should never be ignored. The repositioning of the client and the receiving of a health care provider's order to increase the rate of oxygen delivery would help increase the oxygen saturation. The nurse is caring for a man who was admitted after being found unresponsive at home by his wife. If all of the following assessments and interventions must be completed on this client, place them in order of priority from high priority to lowest. Place the options in the correct order. 1. Performa neurological exam. 2. Obtain blood samples. 3. Prepare a client for a CT scan. 4. Assess and establish the airway. --correct answer--4. Assess and establish the airway. 1. Performa neurological exam. 2. Obtain blood samples. 3. Prepare a client for a CT scan. Rationale: Airway and respiratory status take priority over all other interventions. After this is established, performing a neurological exam is indicated as the first step in determining if the cause of the unresponsiveness is related to a neurological or metabolic cause. Blood would then be drawn in a general physiologic screening as well as in a toxicology screen to determine the presence of drugs as a cause for the unresponsiveness. If the cause of the unresponsiveness is determined to be neurological in origin, a CT scan would be done. The nurse is assisting with prioritization of admission, discharge, and triage of acutely ill clients. Which client would require continued monitoring in the the ICU? Select all that apply. 1. Client with terminal cancer in the process of dying. 2. Client with congestive heart failure and chronic renal failure who develops an exacerbation of the heart failure. 3. Hemodynamically unstable client who requires vasoactive drugs to maintain blood pressure. 4. Client with metastatic lung disease who develops a pneumonia. 5. Client with a tracheostomy who may require mechanical ventilation. -- correct answer--2. Client with congestive heart failure and chronic renal failure who develops an exacerbation of the heart failure. 3. Hemodynamically unstable client who requires vasoactive drugs to maintain blood pressure. 4. Client with metastatic lung disease who develops a pneumonia. Rationale: Priority is given to acutely ill, unstable clients who require invasive procedures or monitoring that cannot occur outside the intensive care area, and who for all purposes have a good chance of surviving their acute illness. What is most appropriate for the nurse to do when interviewing an older patient? a. Ensure all assistive devices are in place. b. Interview the patient and caregiver together. c. Perform the interview before administering analgesics. d. Move on to the next question if the patient does not respond quickly. -- correct answer--a. Ensure all assistive devices are in place. Rationale: All assistive devices, such as glasses and hearing aids, should be in place when interviewing an older patient. It is best to interview the patient and caregiver separately to ensure a reliable assessment related to any possible mistreatment. The patient should be free from pain during the assessment and may need extra time to respond to questions. Which assessment findings would alert the nurse to possible elder mistreatment (select all that apply)? a. Agitation b. Depression c. Weight gain d. Weight loss e. Hypernatremia --correct answer--a. Agitation b. Depression d. Weight loss e. Hypernatremia Agitation and depression may be manifestations of psychologic abuse or neglect. Hypernatremia may signify dehydration caused by physical neglect. A loss of body weight, rather than weight gain, is another clinical manifestation of physical neglect. A 67-year-old woman who has a long-standing diagnosis of incontinence is in the habit of arriving 20 minutes early for church in order to ensure that she gets a seat near the end of a row and close to the exit so that she has ready access to the restroom. Which tasks of the chronically ill is the woman demonstrating (select all that apply)? a. Controlling symptoms b. Preventing social isolation c. Preventing and managing a crisis d. Denying the reality of the problem a. Exercise b. Diabetes c. Social support d. Good nutrition e. Coping resources --correct answer--a. Exercise c. Social support d. Good nutrition e. Coping resources Biologic aging is the progressive loss of function. Obesity, diabetes, hypertension, and cancer are all associated with the effects of aging. Exercise, good nutrition, social support, stress management, and coping resources are all positive factors related to the aging process. A 60-year-old female patient has had increased evidence of dementia and physical deterioration. What would be the best assistance to recommend to her caregiver husband who is exhausted? a. Long-term care b. Adult day care c. Home health care d.Homemaker services --correct answer--b. Adult day care Adult day care provides social, recreational, and health-related services in a safe, community-based environment that would keep this patient safe and decrease the stress on the husband. Long-term care is used when the patient has rapid deterioration, the caregiver is unable to continue to provide care, and there is an alteration in or loss of the family support system. Home health care is used when there is supportive caregiver involvement for patients with health needs. Homemaker services provide services, but do not care for the patient. What should be included when planning care for an older adult? a. Patient priorities should be the only focus of care. b. Additional time related to declining energy reserves c. Reduction of disease and problems should be the focus. d. Tobacco cessation will help the patient cope with other illnesses. --correct answer--b. Additional time related to declining energy reserves Additional time is required with older patients with declining energy reserves. Patient priorities are considered to best meet the patient needs but will not be the only focus of care. Focusing on strengths and abilities as well as physical and mental status will facilitate goal setting to reduce disease or problems. As with all patients, safety is a primary concern, and decreasing tobacco use will improve all of the patient's body functioning. Aging primarily affects the _________of drugs. a. excretion b. absorption c. metabolism d. distribution --correct answer--c. metabolism Because the liver mass shrinks and hepatic blood flow and enzyme activity decrease in older adults, metabolism of drugs drops 1/2 to 2/3 of the rate of young adults. This increases the chance of drug toxicity and adverse drug events. A nurse is caring for an adult who sustained a severe traumatic brain injury following a motor vehicle accident. Once the patient recovers from the acute aspects of this injury and is no longer ventilator-dependent, discharge planning would include that this patient will be transferred to what type of practice setting? a. Assisted living b. Acute rehabilitation c. Long-term acute care d. Skilled nursing facility --correct answer--b. Acute rehabilitation Acute rehabilitation practice settings provide a post-acute level of care specializing in therapies for patients with neurologic or physical injuries, such as those with head trauma, spinal cord injury, or stroke. A nurse with an associate or baccalaureate degree who meets licensing requirements is qualified to practice as: a. a nurse practitioner. b. a certified specialist. c. an entry-level generalist. d. an advanced practice nurse. --correct answer--c. an entry-level generalist Rationale: Entry-level nurses with an associate or baccalaureate degree are prepared to function as generalists. With experience and continued study, nurses may specialize in an area of practice and may obtain certification in nursing specialties. Certification usually requires clinical experience and successful completion of an examination. A nurse practitioner is an example of an advanced practice nurse. An advanced practice nurse has a minimum complete a discharge assessment and provide patient teaching for post- discharge care? A. Registered nurse (RN) B. Nursing technician (NT) C. Unlicensed assistive personnel (UAP) D. Licensed practical/vocational nurse (LPN/LVN) --correct answer--A. Registered nurse (RN) Nursing interventions that require independent nursing knowledge, skill, or judgment such as assessment, patient teaching, and evaluation of care cannot be delegated. These interventions are the responsibility of the RN. The scope of practice for LPN/LVNs is determined by each state board of nursing. The RN must know the legal scope of practical/vocational nursing practice and delegates and assigns nursing functions appropriately. In most states LPN/LVNs may administer medications, perform sterile procedures, and provide a wide variety of interventions planned by the RN. UAP are unlicensed individuals who serve in an assistive role to the RN and may include nursing assistants or technicians. The RN may delegate specific activities such as obtaining routine vital signs on stable patients, feeding/assisting patients at mealtimes, ambulating stable patients, and helping patients with bathing and hygiene. When the nurse encourages a patient with heart failure to alternate rest and activity periods to reduce cardiac workload, what phase of the nursing process is being used? A. Planning B. Diagnosis C. Evaluation D. Implementation --correct answer--D. Implementation Carrying out a specific, individualized plan constitutes the implementation phase of the nursing process. The nurse's action of encouragement and instruction to the patient is part of carrying out a plan of action. When planning care for a patient, the nurse may use a visual diagram of patient problems and interventions to illustrate the relationships among pertinent clinical data. What is this format called? A. Concept map B. Critical pathway C. Clinical pathway D. Nursing care plan --correct answer--A. Concept map A concept map is another method of recording a nursing care plan. In a concept map, the nursing process is recorded in a visual diagram of patient problems and interventions. A clinical (critical) pathway is a prewritten plan that directs the entire health care team in the daily care goals for select health care problems. A nurse is providing care for a patient who had transurethral resection of his prostate this morning. The patient is receiving continuous bladder irrigation, but his urinary catheter is now occluded. The nurse is now planning to phone the patient's health care provider and communicate using the SBAR (Situation-Background-Assessment-Recommendation) format. Which statement is a component of communication using SBAR? A. "What do you think could be causing this occlusion?" B. "I think that we should manually irrigate his catheter." C. "What do you know about this patient and his history?" D. "Could you please provide some direction for his care?" --correct answer- -B. "I think that we should manually irrigate his catheter." Proposing a recommendation is a component of the "R" component of SBAR communication. Asking the health care provider for possible contributing factors to the problem or for general direction may be appropriate in some circ*mstances, but these are not explicit components of SBAR. The nurse should briefly identify the patient and his circ*mstances, not ask an open- ended question regarding the physician's familiarity. What factor has been most clearly identified as an influence on the future of nursing practice? A. Aging of the American population and increases in chronic illnesses B. Increasing birth rates coupled with decreased average life expectancy C. Increased awareness of determinants of health and improved self-care D. Apathy around health behaviors and the relationship of lifestyle to health --correct answer--A. Aging of the American population and increases in chronic illnesses The American population is aging at the same time that the incidence of chronic health conditions is increasing. There is no noted increase in the overall awareness of the determinants of health, but at the same time, observers have not identified apathy as a predominant attitude. Life expectancy is increasing, not decreasing. A group of nurses have a plan to implement evidence-based practice (EBP) for care of patients with pressure ulcers. What will this change in practice encompass (select all that apply)? A. Administering medications B. Evaluation of weight loss C. Video assessment of wounds D. Monitoring peak flow meter results E. Real-time blood pressure assessment --correct answer--A. Administering medications B. Evaluation of weight loss C. Video assessment of wounds D. Monitoring peak flow meter results E. Real-time blood pressure assessment Telehealth enables the nurse to provide distance assessment, planning, intervention, and evaluation of outcomes of nursing care using technologies such as the Internet, digital assessment tools, and telemonitoring equipment. What factor has been most clearly identified as an influence on the future of nursing practice? a. Aging population and chronic illness b. Increasing birth rates coupled with decreased average life expectancy c. Increased awareness of detriments of health and improved self care d. Apathy around health behaviors and the relationship of lifestyle to health. --correct answer--a. Aging population and chronic illness The American population is aging at the same time that the incidence of chronic health conditions is increasing. There is no noted increase in the overall awareness of the determinants of health, but at the same time, observers have not identified apathy as a predominant attitude. Life expectancy is increasing, not decreasing. Nurses deliver patient-centered care in collaboration with the interdisciplinary health care team within the framework of a care delivery model. In which care delivery model does the nurse plan and coordinate the aspects of patient care with other disciplines with a focus on continuity of care and interdisciplinary collaboration even when the nurse is absent? a. Team nursing model b. Primary nursing model c. Total patient care model d. Case management nursing model --correct answer--b. Primary nursing model Primary nursing model includes planning the patient's care, coordinating and communicating all aspects of care with other disciplines and those providing care in the nurse's absence. The focus is on continuity of care and interdisciplinary collaboration. Team nursing uses the RN as the team leader to organize and manage the care for a group of patients with other ancillary workers. The RN has authority and accountability for the quality of care delivered by the team only during the work period. In a total patient care model, the nurse is accountable for the complete care of the patient during the assigned shift. Case management is not a model of care delivery, but a collaborative process that involves assessing, planning, facilitating, and advocating for health services with a variety of resources to promote cost-effective outcomes. A group of nurses have a plan to implement evidence-based practice (EBP) for care of patients with pressure ulcers. What will this change in practice encompass (select all that apply)? Select one or more: a. Consulting with the wound care and ostomy nurse b. The preferences of patients and their particular circ*mstances c. Nurses' expertise and their bodies of experience and knowledge d. The traditions that surround pressure ulcer practices on the unit e. Journal articles that address the care of patients with pressure ulcers . --correct answer--a. Consulting with the wound care and ostomy nurse e. Journal articles that address the care of patients with pressure ulcers. a:EBP draws on research, data from local quality improvement, professional organization standards, patient preferences, and clinical expertise. The particular traditions on the nursing unit are not part of EBP. e: EBP draws on research, data from local quality improvement, professional organization standards, patient preferences, and clinical expertise. The particular traditions on the nursing unit are not part of EBP. A registered nurse (RN) has delegated the administration of IV medications to a licensed practical/vocational nurse (LPN/LVN). Which statement accurately describes delegation? Select one: a. The RN should first teach the LPN how to administer IV medications. b. Ultimate responsibility for the execution of the task now lies with the LPN. c. The RN is still accountable for the quality of care and procedures that the patient receives. --correct answer--c. The RN is still accountable for the quality of care and procedures that the patient receives. Rationale:The RN is still accountable for the quality of care and procedures that the patient receives. Correct In order to qualify for Medicare, an individual must be entitled to receive Social Security benefits. Absence of caregivers and inadequate responses to treatment are not qualification criteria for Medicare, and the program does not cover residential care services. What is most appropriate for the nurse to do when interviewing an older patient? a. Ensure all assistive devices are in place b. Interview the patient and caregiver together. c. Perform interview before administering analgesics d. Move onto to next question if the patient does not respond quickly. -- correct answer--a. Ensure all assistive devices are in place. All assistive devices, such as glasses and hearing aids, should be in place when interviewing an older patient. It is best to interview the patient and caregiver separately to ensure a reliable assessment related to any possible mistreatment. The patient should be free from pain during the assessment and may need extra time to respond to questions. A 70-year-old man has just been diagnosed with chronic obstructive pulmonary disease (COPD). At what point should the nurse begin to include the patient's wife in the teaching around the management of the disease? a. As soon as possible b. When the patient requests assistance from his spouse and family c. When the patient becomes unable to manage his symptoms independently d. After the patient has had the opportunity to adjust to his treatment regimen --correct answer--a. As soon as possible In the management of chronic illness, it is desirable to include family caregivers in patient education and symptom-management efforts as early in the diagnosis as possible. Aging primarily affects the _________of drugs. a. excretion b. absorption c. metabolism d. distribution --correct answer--c. metabolism Because the liver mass shrinks and hepatic blood flow and enzyme activity decrease in older adults, metabolism of drugs drops 1/2 to 2/3 of the rate of young adults. This increases the chance of drug toxicity and adverse drug events. What should be included when planning care for an older adult? a. patient priorities should be the focus of care. b. Additional time related to declining energy reserves. c. Reduction of disease and problems should be the focus. d. Tobacco cessation will help the patient cope with other illnesses. --correct answer--b. Additional time related to declining energy reserves. Additional time is required with older patients with declining energy reserves. Patient priorities are considered to best meet the patient needs but will not be the only focus of care. Focusing on strengths and abilities as well as physical and mental status will facilitate goal setting to reduce disease or problems. As with all patients, safety is a primary concern, and decreasing tobacco use will improve all of the patient's body functioning. A male patient has a history of hypertension and type 1 diabetes mellitus. Because of these chronic illnesses, the patient exercises and eats the healthy diet that his wife prepares for him. Which factors will most likely have a positive impact on his biologic aging (select all that apply)? a. Exercise b. Diabetes c. Social support d. Good nutrition e. Coping resources --correct answer--a. Exercise c. Social support d. Good nutrition a: Biologic aging is the progressive loss of function. Obesity, diabetes, hypertension, and cancer are all associated with the effects of aging. Exercise, good nutrition, social support, stress management, and coping resources are all positive factors related to the aging process. c: Biologic aging is the progressive loss of function. Obesity, diabetes, hypertension, and cancer are all associated with the effects of aging. Exercise, good nutrition, social support, stress management, and coping resources are all positive factors related to the aging process. d: Biologic aging is the progressive loss of function. Obesity, diabetes, hypertension, and cancer are all associated with the effects of aging. Exercise, good nutrition, social support, stress management, and coping resources are all positive factors related to the aging process. A nurse is caring for an adult who sustained a severe traumatic brain injury following a motor vehicle accident. Once the patient recovers from the acute 5. Restrict fluids. --correct answer--2. Keep the head of the bed above 30 degrees. 3. Perform oral care at least every 4 hours. 4. Reposition the patient every 2 hours. A patient is complaining of increased shortness of breath. The nurse observes a respiratory rate of 24 on 3LPM of oxygen via nasal cannula. Which of the following actions should be done initially? 1. Administer a bronchodilator as ordered. 2. Conduct a comprehensive respiratory assessment. 3. Increase oxygen flow rate 4. Notify the physician --correct answer--2. Conduct a comprehensive respiratory assessment Rationale: The nurse should first assess the patient's respiratory system to identify abnormalities to report. The nurse may increase the oxygen flow rate if the patient is not maintaining an oxygen saturation above 90% but should notify the physician of the increased oxygen requirements. The nurse is caring for a postoperative patient at risk for pneumonia. What interventions should be implemented to reduce the risk of pneumonia? Select all that apply. 1. Best rest 2. Coughing 3. Early ambulation 4. Frequent repositioning 5. Incentive spirometry 6. Limiting fluids --correct answer--2. Coughing 3. Early ambulation 4. Frequent repositioning 5. Incentive spirometry Rationale: To prevent the development of pneumonia, the patient should cough, deep breath, reposition frequently and ambulate early, and take medication for pain. Bed rest and limiting fluids will increase the risk of pneumonia. The nurse is caring for a patient suspected of having lung cancer. The physician performs a bronchoscopy to obtain a biopsy. Which of the following should be reported to the physician? 1. Bronchospasm 2. Cough 3. Dark red sputum 4. Drowsiness --correct answer--1. Bronchospasm Rationale: Bronchospasms are an unexpected side effect and should be reported to the physician immediately to prevent respiratory failure. Cough and drowsiness from conscious sedation are expected side effects. Red sputum is expected after a biopsy for several hours in small amounts. The nurse is caring for a patient with a GI bleed who is SOB but has clear lung sounds and an oxygen saturation of 98%. Which of the following is the most probably cause for the patient's symptoms? 1. A psychiatric disorder 2. Heart failure 3. Hematologic problem 4. Poor perfusion to the extremities --correct answer--3. Hematologic problem Rationale: The patient most likely has anemia due to the GI bleed. The patient's oxygen saturation is normal because the small amount of hemoglobin is saturated with an adequate amount of oxygen, but the hemoglobin levels are still low. This is a hematologic problem that is causing respiratory symptoms. Heart failure would result in abnormal breath sounds. Poor perfusion to the extremities would result in poor oxygen saturation as well as cool/cold extremities. The nurse assesses a patient suspected of having a pleural effusion. Which of the following are the most common clinical manifestations of this condition? 1. Dry, nonproductive cough and crackles over the affected area. 2. Dry, nonproductive cough and diminished breath sounds. 3. Productive cough and crackles over the affected area. 4. Productive cough and diminished breath sounds over the affected area. -- correct answer--2. Dry, nonproductive cough and diminished breath sounds. Rationale: A pleural effusion is the abnormal accumulation of fluid in the pleural space. Pleural effusions present with pleuritic pain, dry nonproductive cough, dyspnea on exertion, tachycardia, and diminished breath sounds of the affected area. Pleural friction rub, which is identified by abnormal sounds heard during inspiration and expiration that range from squeaking to crackling, or grating is a hallmark sign of pleural effusions, but is less common. Which type of transmission based precaution technique should the nurse implement for the client diagnosed with bacterial meningitis? 1. Standard 2. Airborne 3. Enteric 4. Droplet --correct answer--4. Droplet Rationale: According to the CDC, some diseases require precautions to limit the risk of infection to others. Standard precautions are required for all clients and include hand hygiene. Communicable diseases that are condition that is precipitated by multiple triggers. Acute exacerbations may be frequent but are not necessarily a sign of neglect. The nurse is teaching a client with newly diagnosed emphysema how to manage the disease. The client asks how pursed lip breathing helps the emphysema. What would be the best response by the nurse? 1. It prevents air sacs in the longs from trapping air. 2. It decreases the pressure in the airways. 3. The resistance on exhalation increases the muscle strength in the diaphragm. 4. It helps slow down respiratory rate. --correct answer--1. It prevents air sacs in the longs from trapping air. Rationale: Pursed-lip breathing is a technique used by individuals with COPD where clients exhale through pursed lips. This increases airway pressure, delays the airway compression that occurs with exhalation, and reduces air trapping in the alveoli. The potential slowing of the respiratory rate is incidental and unrelated to why it is used. R The nurse is caring for a client diagnosed with pneumothorax which is being treated with a chest tube to re-expand the lung. Which actions are appropriate for the nurse to take when caring for this client? Select all that apply. 1. Clamp chest tube when assisting client from bed to chair. 2. Report fluctuations in water seal section of chest drainage system. 3. Maintain an occlusive dressing, such as petrolatum gauze around chest tube at insertion site. 4. Gently massage chest tubes hourly to promote drainage. 5. Encourage client to maintain a high Fowler's position. --correct answer-- 3. Maintain an occlusive dressing, such as petrolatum gauze around chest tube at insertion site. 5. Encourage client to maintain a high Fowler's position. Rationale: Chest tubes are inserted into the pleural space to drain fluids or air from the pleural space and promote lung re-expansion. If the drainage system is occluded in any way, re-expansion can be prevented or fluid and air can accumulate and cause a tension pneumothorax. Fluctuations in the water seal are normal and represent normal inspiration and expiration. The chest tube has tiny holes at the tip and promote drainage. Respiration can cause the tube to slide in and out of the insertion site, which could potentially cause one of the small holes to be located on the outside of the thoracic The nurse is caring for a client in the short procedure until (SPU) following a bronchoscopy using moderate (conscious) sedation. Prior to discharging the client, the nurse verifies that the client has achieved which priority outcomes? 1. Verbalizes symptoms of late complications 2. Demonstrates an intact gag reflex 3. Remains afebrile for up to 2 post-op days 4. Reports being thirsty and asks for oral fluids --correct answer--2. Demonstrates an intact gag reflex: indicates that topical sedation has lost its effect and the client is able to swallow. If not present, the client is at risk for aspiration pneumonia if they eat The nurse is caring for a 68 year old client who is scheduled for discharge later that day. An arterial blood gas done the previous morning reveals a PaO2 of 87 mmHg. The client has a respiratory rate of 22 and clear lungs and reports no shortness of breath. What should be the nurses response? 1. Call the health care provider to report to PaO2 2. Monitor the client more closely because a physiological abnormality is beginning 3. Do nothing because a PaO2 of 87 is normal in an older adult 4. Call the family and tell them to anticipate that the discharge will be canceled --correct answer--3. Do nothing because a PaO2 of 87 is normal in an older adult: normal levels of PaO2 are 80-100 mmHg The nurse is caring for a client diagnosed with right middle lobe pneumonia. The nurse should perform which intervention to mobilize secretions? 1. Administer antibiotics as ordered 2. Limit fluids to intravenous fluids only 3. Place the client in a prone position to increase alveolar expansion 4. Assist client to use incentive spirometer hourly --correct answer--4. Assist the client to use incentive spirometer hourly: promotes maximum lung expansion, mobilizes secretions, and encourages cough. Which type of transmission based precaution technique should the nurse implement for the client diagnosed with bacterial meningitis? 1. Standard 2. Airborne 3. Enteric 4. Droplet --correct answer--4. Droplet: Meningitis is transferred through large droplet particles from the infected person, usually through the oropharynx A postoperative client with emphysema is receiving oxygen at 2 L/min via nasal cannula when the client reports shortness of breath. The spouse asks the nurse to increase the oxygen to help the client breathe easier. Which response by the nurse is appropriate? 1. "I have a better technique; I will switch him to 100% non-rebreather mask." 5. Encourage client to maintain a high Fowler's position --correct answer--3 & 5: an occlusive dressing prevents re-collapse of the lungs and an upright position promotes lung expansion The nurse is caring for a client just admitted with a diagnosis of pulmonary cystic fibrosis (CF). What would be the priority goal when planning care for this client? 1. Improving airway clearance 2. Removing allergens from the environment 3. Eliminating foods that are known to cause intolerance 4. Preparing client for the CF-specific sweat test --correct answer--1. Improving airway clearance: CF is characterized by excessive secretions which can impact airway clearance. It is important to improve airway clearance by helping the client rid and thin secretions. A sweat test is performed in diagnosis, although in this situation the client has already been diagnosed Which arterial blood gas report would the nurse expect in a client with advances chronic obstructive pulmonary disease (COPD)? 1. pH: 7.55, PaCO2 30mmHg, PaO2 80 mmHg, HCO3 -24 mEq/L 2. pH: 7.4, PaCO2 40 mmHg, PaO2 94 mmHg, HCO3 -22 mEq/L 3. pH: 7.38, PaCO2: 45 mmHg, PaO2: 88mmHg, HCO3: -24 mEq/L 4. pH: 7.30, PaCO2: 60 mmHg, PaO2: 70 mmHg, HCO3: -30 mEq/L --correct answer--4. pH: 7.30, PaCO2: 60 mmHg, PaO2: 70 mmHg, HCO3: -30 mEq/L During the later stages of COPD, ABGs indicate a low pH (<7.35), elevated PaCO2 (>45 mmHg), low PaO2 (<80 mmHg), and elevated HCO3 (>28 mEq/L) The nurse considers that which concept should have priority for discussion during discharge teaching for client who has chronic bronchitis? 1. Fluid restriction 2. Smoking cessation 3. Avoidance of crowds 4. Side effects of drug therapy --correct answer--2. Smoking cessation: smoking is the primary etiology of chronic bronchitis so cessation is the priority for the client. A client diagnosed with HIV has returned to the clinical 72 hours after a tuberculin skin test was given and there is an induration of 6 mm at the administration site. Thee client is visibly upset and states, "I can't believe I have TB!" Which statement by the nurse is most appropriate? 1. "Don't worry, this is a good result. At least it is not 10 mm." 2. "The doctor will prescribe ionized for you to take for the next 3 months." 3. "This finding does not confirm TB; it may indicate a recent exposure to tuberculosis" 4. "We'll need to do a chest x-ray. This may be false positive because your history of HIV" --correct answer--3. In HIV positive clients, an induration of 5-10 mm after TB skin test indicated exposure to an individual infection with mycobacterium tuberculosis. HIV history is not related to false positives, but is related to a positive result at measurements of greater than 5mm. They are at an increased risk for infection. The nurse is caring for a client with a tracheostomy tube. The nurse keeps which concept in mind while caring for this client? 1. Client must be suctioned as needed using clean technique 2. Tracheotomy tube must be capped to allow client to eat by mouth. 3. The oxygen or air needs to be humidified 4. Saline can be inserted into the tracheotomy tube before suctioning if secretions are thick --correct answer--3. The oxygen of air needs to be humidified: Tracheostomy bypasses the normal airway's humidification, supplemental humidification is needed to keep the airways moist and prevent mucous plugs and airway occlusion from occurring. The registered nurse (RN) has an unlicensed assistive person (UAP) assigned to help with the clients. Which task can the RN delegate to the UAP? Select all that apply. 1. Perform routine measurement of clients peak expiratory flow rate 2. Switch supplemental oxygen from face mask for nasal cannula 3. Teach the client how to use the incentive spirometer 4. Administer nebulizer treatment for the client with recurrent asthma exacerbation 5. Ambulate a client who has had a chest tube removed 8 hours prior. -- correct answer--1 & 5:; The RN is ultimately responsible for care although assessing stable clients with routine needs is within he scope of practice for UAP. A client has a right chest tube post-thoracotomy. When assessing the client to ambulate, the nurse should use what measure to maintain functioning of the closed chest drainage system? 1. Keep collection device below the level of the chest 2. Clamp the chest tube before assisting the client out of bed 3. Milk chest tube when client returns to bed to re-establish airway 4. Connect collection device to a portable suction machine. --correct answer- -1. Keep the collection device below the level of the chest: this promotes drainage, maintains the water seal and prevents back flow of air and fluid into the chest. Chest tubes should never be clamped. Milking causes negative pressure which can result in problems. A client is brought to the ED after his motor vehicle crashed into a tree. Which finding suggests to the nurse that the client has experienced a tension pneumothorax? 1. Tachypnea 2. Hypotension 3. Tracheal deviation 5. Falls asleep when not disturbed --correct answer--1, 3, & 4: compensation for lack of blood flow increasing HR, crackles and sputum are usually signs, and are not able to breathe effectively. A client is scheduled for coronary angiography. In reviewing the client's record, which significant finding would the nurse report to the health care provider before the diagnostic procedure? 1. A client reported an allergy to iodine. 2. Client's electrocardiogram shows atrial fibrillation 3. Potassium level is 4,0 mEq/L 4. Client has a history of chronic renal failure --correct answer--1. A client reported an allergy to iodine: the dye used in angiography is iodine based (allergy to shellfish) The nurse is implementing a discharge teaching plan for a client newly diagnosed with FH. When discussing fluid status with the client, the nurse would explain the importance of doing which of the following? 1. Restricting fluid intake to approximately 800 mL/day 2. Taking a single extra dose of diuretic is there is decreased urination for several days 3. Recording body weight every day before breakfast and report a weight gain of 3 or more pounds in a week 4. Keeping track of daily output and calling healthcare provider if it is less than 1 L on any day --correct answer--3. Daily weight is the most sensitive indicator of changes in fluid status. Taking weight before eating and after voiding enables comparisons from day to day. Weight gain of >3lbs/week should be reported. Fluid restriction is normal in advanced HF. Weight is more accurate than output. A client is getting ready to go home after acute myocardial infarction. The client is asking questions about the prescribed medications, and wants to know why metoprolol was prescribed. The nurse's best response would be which of the following? 1. "You heart was beating too slowly, and metoprolol increases your heart rate" 2. Lopressor helps to increase the blood supply to the heart by dilating the coronary arteries" 3. Lopressor helps make your heart beat stronger to supply more blood to your body 4. Lopressor slows your heart rate and decrease the amount of work it has to do so it can heal --correct answer--4. "Lopressor slows our heart rate and decreases the amount of work it has to do so it can heal": beta blockers slow the HR and decrease myocardial contractility. This reduces cardiac workload. A client is taking digoxin and furosemide for HF. The nurse approved of which of the following client selections that is the best menu choice for this client? 1. Chicken with baked potato and cantaloupe 2. Ham and cheese omelet with low-cholesterol egg substitute 3. Grilled cheese sandwich with pan browned potatoes 4. Pizza with low fat mozzarella cheese and pepperoni --correct answer--1. Chicken with baked potato and cantaloupe: furosemide is a loop diuretic, causing a loss of potassium. Taken with digoxin can increase risk of dig. toxicity. Therefore in order to decrease the risk, a diet high in potassium and low in sodium should be followed The nurse is caring for a client with a diagnosis of restrictive cardiomyopathy. When planning this client's care, which of the following would be the most appropriate nursing diagnosis? 1. Fear related to new onset of symptoms 2. Hopelessness related to lack of cure and debilitating symptoms 3. Deficient knowledge related to medication regime 4. Activity intolerance related to decreased cardiac output --correct answer-- 4. Activity intolerance related to decreased cardiac output: all clients with cardiomyopathy have some decrease int heir cardiac output and corresponding activity intolerance. The nurse working on a cardiac telemetry unit prepared to use an external pacemaker after noting that an assigned client has a blood pressure of 70/52 and has developed which cardiac dysrhythmia that is amenable to this therapy? Select all that apply. 1. Ventricular fibrillation 2. Atrial fibrillation 3. Ventricular tachycardia 4. Second-degree heart block 5. Third-degree heart block --correct answer--4 & 5: Clients with severe bradycardia, second-degree heart block, and third-degree heart block are those who are most likely to need an external pacemaker as a temporary therapy until definite treatment can be given A client is prescribed sublingual nitroglycerine for the treatment of angina pectoris. The nurse concludes that what response from the client indicates understanding of this medication? 1. "My health care provider gave me a year's supply of nitroglycerine tablets" 2. "I will carry my nitro tabs in the inside pocket of my jacket, so they are always close" 3. "I usually take 3 of my nitro tabs at the same time. I find that they work better that way" 4. "I have a small metal labeled case for a few nitro tabs that I carry with me when I go out" --correct answer--4. "I have a small metal labeled case for a few nitro tabs that I carry with me when I go out": nitro is light sensitive 2. "If you bend your leg, you will risk bleeding from the insertion site. It is an artery, and it could lead to complications" 3. "If you get out of bed you may have an arrhythmia from the catheterization. Your heart has to rest after this procedure" 4. "The doctor has ordered that you stay on bed rest for the next 6 hours. It is important that you follow these orders" --correct answer--2. "If you bend your leg, you will risk bleeding from the insertion site. It is an artery, and it could lead to complications": Bed rest is prescribed to allow the arterial puncture to seal and reduce the risk of bleeding. The nursing is caring for aliment admitted to the ED with chest pain. He reports that chest pain developed while mowing the lawn and he stopped and rested on the sofa, which is typical for him. This time the pain was not relieved by rest so he came to the ED. The chest pain is relieved following administration of 2 sublingual nitroglycerine tabs. The nurse draws which conclusion about the clients status? 1. Client most likely has stable angina 2. Client has a knowledge deficit because he did not take his sublingual nitro 3. Client most likely has unstable angina 4. Client most likely has acute MI --correct answer--3. Client most likely has unstable angina: When the character of chest pain changes for it is unrelieved by the usually measures the client has unstable angina and is correct to go to the ED. Stable angina is predictable and is usually relieved with rest. The nurse is assessing a client at 7:30 am on a day when the client has a cardiac stress test scheduled for 11:30. The client reports that no breakfast was delivered this morning and the client is hungry. When is the nurse's best action? 1. Bring client coffee and toast 2. Explain that client should have no food the morning of the cardiac stress test 3. Call nutrition department and get the client's regular full breakfast 4. Have nursing assistant get the client cereal with milk and orange juice -- correct answer--4. Have nursing assistant get the client cereal with milk and orange juice: The client should have a light meal with no caffeine before a cardiac stress test and should refrain from eating or drinking 2-3 hours before the test. A hospitalized client has continuous electrocardiographic (ECG) monitoring, and monitors shows that the rhythm suddenly changed to ventricular tachycardia (VT). Upon entering the room, the nurse notes that client is awake and alert and speaks to the nurse. What are priority actions that the nurse should take? Select all that apply. 1. Administer intravenous lidocaine according to emergency protocol 2. Obtain the defibrillator and defibrillate the client 3. Quickly assess the client's blood pressure and pulse 4. Administer a precordial thumb 5. Ask the unit secretary to telephone the clients family --correct answer--1 & 3: The best first action is to assess the client's LOC and assess if the ventricular tachycardia is perfusing the body by measuring the BP and pulse. If the client has a good BP and HR and is awake and alert, the nurse ay administer IV lidocaine as ordered. The physician has diagnosed acute MI on the basis of electrocardiogram (ECG) changes for a client in the ED. The nurse assesses the client frequently, and notes that the client seem forgetful, and periodically asks the nurse to explain the ECG and noninvasive blood pressure monitors. The nurse concluded that the client's response is most likely due to which of the following reasons? 1. Client is showing signs of very early Alzheimer's disease 2. Client is showing signs of fear and anxiety 3. Nurses in the ER are busy and provide explanations that they are short 4. Memory lapses are coming with clients experiencing MI --correct answer- -2. Client is showing signs of fear and anxiety: anxiety and fear are common responses to a diagnosis of MI because of the possibility of death. This prevents the client from absorbing material, memory lapses are not common results of MI. What are the laboratory tests used in patients with heart failure? --correct answer--BNP Iron levels should be normal; supplementation may be necessary Kidney and thyroid function tests may be performed as well: kidneys for filtration Cholesterol levels: is it related? What are guidelines for resuming sexual activity post MI? --correct answer-- Sexual intercourse is generally equal to climbing 2 flights on stairs, so it is very energy depleting. Nurses should supply guidelines to patients who wish to resume sexual activity in order to decrease work load on the heart. This may include being on the bottom during intercourse. Being with a long term partner can make this easier. What are the clotting tests performed for patients taking heparin? Warfarin? --correct answer--Heparin: aPtt Warfarin: PT/INR How would a nurse care for a superficial thrombosis at an IV site? --correct answer--Apply a warm compress to help the clot pass. Deep vein thrombosis there are usually no nursing interventions except to avoid movement and touching of the extremity. Warm compress usually helps the clot pass and results in no problems. answer--The client receiving Procrit (epoetin alfa) has a T 99.2˚F, P 68, R 24, and BP of 198/102 The client diagnosed with lung cancer has been told the cancer has metastasized to the brain. Which intervention should the practical nurse expect to implement? --correct answer--Discuss implementing an advance directive The client diagnosed with lung cancer is being discharged. Which statement made by the client indicates a reiteration of information is required? -- correct answer--"It doesn't matter if I smoke now. I already have cancer." The practical nurse is interviewing clients at the clinic. Which information provided by a client warrants further investigation? --correct answer--The client has been coughing up blood in the mornings The male client had abdominal surgery and the practical nurse suspects the client has peritonitis. Which information support the diagnosis of peritonitis? --correct answer--Hard, rigid abdomen and white blood cell count 22,000/mm3 The client who had abdominal surgery tells the practical nurse, "I felt something give way in my stomach." Which intervention should the practical nurse implement first? --correct answer--Inspect the abdominal wound incision The client is one (1) day postoperative major abdominal surgery. Which client problem is a priority? --correct answer--Fluid and electrolyte imbalance The client has an eviscerated abdominal wound. Which intervention should the practical nurse implement? --correct answer--Apply sterile normal saline dressing The client is diagnosed with peritonitis. Which information indicates to the practical nurse the client's condition is improving? --correct answer--The client has a decrease in temperature and a soft abdomen A patient is being released from the hospital with a prescription for tetracycline. What should the nurse include in patient teaching? Select all that apply. --correct answer--Advise limiting exposure to the sun. Inform patient of the possibility of gastrointestinal upset. Suggest eating crackers and some juice when taking this medicine. The nurse wants to determine if a patient not fully awake from anesthesia for a surgical procedure is experiencing pain. What findings should the nurse use to make this determination? Select all that apply. --correct answer--Moaning Restlessness Pulling at a body area Elevated blood pressure A patient is diagnosed with an infection that has spread to the blood stream. Which term should the nurse use to document this patient's health problem? --correct answer--Sepsis The nurse learns that a patient is being admitted with an infectious disease that is transmited through the air. For which health problems should the nurse prepare to provide care? Select all that apply. --correct answer--Measles Tuberculosis Chickenpox A patient is diagnosed with Rocky Mountain spotted fever. What should the nurse explain as the method by which this disease was transmitted to the patient? --correct answer--Ticks A patient returning from the recovery room following abdominal surgery to drain an abscess has a nonsuction-type drain placed in the wound bed to allow drainage. Which drain should the nurse expect to see? --correct answer--Penrose drain A patient has an epidural catheter placed for pain control. Which medications should the nurse question before providing them to the patient during routine medication administration? Select all that apply. --correct answer--Aspirin 325 mg by mouth once a day Warfarin (Coumadin) 2.5 mg by mouth every evening A patient with severe arthritis pain is prescribed celecoxib (Celebrex). What should the nurse instruct the patient about this medication? --correct answer--Take with food. The nurse is caring for a patient exposed to a toxin. Which is the most potent lethal toxin? --correct answer--Botulinum The nurse is assisting in the care of a patient with suspected anaphylactic shock. Which orders should the nurse question? Select all that apply. --correct answer--Morphine 2 mg intravenous (IV) now Transfuse with 1 unit of packed red blood cells over 1 hour The nurse is preparing to assess a patient receiving chemotherapy and radiation for adverse effects of the treatments. In which order (1-5) should the nurse assess the patient for these adverse effects? Place the effects in the order in which they should be assessed. --correct answer--Emesis Infection Bleeding the nurse respond to this patient's plan? --correct answer--"Massage therapy should be used in addition to the pain medication." Fory-eight hours after surgery a patient continues to have no bowel sounds. What should the nurse do to promote the return of bowel function in this patient? Select all that apply. --correct answer--Assist to ambulate. Provide the patient with chewing gum. A patient is diagnosed with conjunctivitis. The nurse should explain that the patient was infected via which mechanism? --correct answer--Vehicle-borne The nurse is preparing materials to instruct an older patient recovering from septic shock. What should the nurse keep in mind when teaching this patient? Select all that apply. --correct answer--Speak slowly and clearly. Speak in a low-pitched tone. Provide materials in large print. Involve family members in teaching. During the primary survey, the nurse has determined that the airway is unobstructed, but the patient is not breathing. What action should take priority? --correct answer--Ventilate the patient immediately The nurse notes that a patient's laboratory values indicate abnormal clotting, decreased production of proteins, and increased serum ammonia levels. Which organ should the nurse suspect is damaged in this patient? -- correct answer--Liver The nurse is preparing to administer an opioid analgesic. Which assessment findings should be evaluated and documented prior to administering the medication? --correct answer--Pain level and respiratory rate A patient is diagnosed with an illness caused by a prion. The nurse should plan patient care for which diseases process? --correct answer--Creutzfeldt- Jakob syndrome A patient is prescribed an antibiotic to treat a lung infection. What should the nurse emphasize to the patient about this medication? Select all that apply. --correct answer--Take all of the medication as prescribed. Report evidence of side effects to the HCP. A patient who was impaled on a piece of pipe is brought to the emergency department with a piece of metal rod protruding from the lower chest area. Which action should the nurse take first? --correct answer--Apply a bulky dressing around the impaled object. A patient is having a regional block where a tourniquet is placed on an extremity to reduce the blood in the extremity and then have a local agent injected into the extremity. What type of block should the nurse document? --correct answer--Bier block The nurse is reviewing cancer statistics prior to obtaining morning report for a group of oncology patients. Which cancer does the nurse realize is associated with the highest mortality rate? --correct answer--Lung cancer A patient has been receiving 10 mg morphine IV every 4 to 6 hours for postoperative pain. At discharge, the patient rates the pain as a 4 on a 0-10 scale. On a prescription to be given to the patient at discharge, the physician has written morphine 10 mg by mouth four times a day as needed. What should the nurse do first? --correct answer--Contact the physician regarding the prescription. A patient is experiencing moderate-to-severe pain. Which pain medication should the nurse expect to be prescribed for this patient? --correct answer-- Morphine The nurse plans interventions for a patient in shock to address circulatory collapse. What is the goal for this patient's care? --correct answer--Prevent organ damage The nurse is caring for a patient with preexisting liver dysfunction experiencing shock. Which acid-base imbalance should the nurse anticipate this patient developing? --correct answer--Metabolic acidosis An older patient receiving antibiotics for an abdominal wound infection develops a fever and diarrhea. What treatment should the nurse prepare to provide to this patient? Select all that apply. --correct answer--Provide metronidazole (Flagyl) if prescribed. Provide vancomycin (Vanocin) if prescribed. Use hand washing with soap and water after all patient care. Stop the administration of the currently prescribed antibiotic. The nurse is reviewing the laboratory results for several patients. Which laboratory tests are tumor markers that can confirm the diagnosis of cancer? Select all that apply. --correct answer--Alpha-fetoprotein The nurse is reviewing the process of pain perception and control. In which group of chemical substances should the nurse find prostaglandins and substance P? --correct answer--Neurotransmitters During a home visit, the nurse is collecting data from a patient recovering from spinal surgery conducted 3 weeks ago. Which wound finding should the nurse expect in the patient? --correct answer--Raised scar The nurse is assisting in the care of a patient admitted with suspected carbon monoxide poisoning. Which laboratory value should the nurse evaluate first? --correct answer--Carboxyhemoglobin Five patients with suspected smallpox exposure are brought into the emergency department. What actions should the nurse take to prevent exposure to other patients and health care personnel? Select all that apply. --correct answer--Cleanse room surfaces with ammonia. Apply surgical masks to each of the patients. Place the patients' laundry and linens in biohazard bags. Staff should wear fit-tested N95 respirators if not vaccinated against smallpox. The nurse is planning interventions for a patient with shock. On which body organ should the nurse focus interventions first? --correct answer--Kidneys During morning report, the nurse caring for a patient experiencing chronic pain doubts the patient is in pain and does not want to provide any pain medication all shift. What myths about pain should the nurse manager review with the nurse? Select all that apply. --correct answer--Pain is often overtreated A patient who is talking on the phone and laughing is not really in pain. Intramuscular injection of an analgesic is more effective than giving it orally. Addiction to opioids given to relieve pain is common, especially in teenagers. Morphine has a ceiling effect; therefore, its use should be reserved for severe pain. A patient is diagnosed with distributive shock. What should the nurse explain to the family as the cause of this type of shock? --correct answer-- Excessive dilation of venules and arterioles A college student is brought into the emergency department with possible frostbite of both feet after losing consciousness in a snow drift while walking home from a party. What actions should the nurse take at this time? Select all that apply. --correct answer--Handle the feet gently. Elevate the feet to heart level. Cover the feet with dry sterile gauze. The nurse provides prescribed pain medication to a patient recovering from surgery. What additional actions should the nurse take to provide comfort for this patient? Select all that apply. --correct answer--Relieve a full bladder Reduce overhead lighting Reduce environmental noise Place in a comfortable position A patient with a neck injury is experiencing nausea and begins to vomit. What should the nurse do to help this patient? --correct answer--Log roll onto one side. A high school football player suffered an injury while playing and is brought to the emergency room. The primary survey shows an alert patient with patent airway, breathing, a carotid pulse, and skin color within normal limits. The patient reports, "I can't flex my foot or point my toes." On which area should the nurse expect diagnostic tests to focus for this patient? -- correct answer--The lower back The nurse suspects a patient is experiencing anaphylaxis after a bee sting to the arm. What did the nurse most likely assess in this patient? Select all that apply. --correct answer--Decreasing blood pressure Respiratory distress with stridor Increased fluid and mucus in bronchial passages The nurse is assisting the patient who has a urinary catheter with bathing. The urinary bag has 300 milliliters of clear pale yellow urine and is placed below the level of the bladder. The nurse notes that the catheter moves freely when the patient turns. Which action should the nurse take to decrease the patient's risk for urinary infection? --correct answer--Secure urinary catheter per agency policy. A patient is diagnosed with a type of cancer that affects the skin and urinary system. What term should the nurse use to describe this type of cancer? -- correct answer--Carcinoma During pre-admission, the data collection for a 24-year-old woman scheduled for a cholecystectomy includes a complete blood count and chest radiograph based on her age and medical history. What other test should the nurse anticipate being ordered? --correct answer--Pregnancy test A 2-day postoperative patient is receiving 1000 mL normal saline over 10 hours. The patient has an intake of 4 ounces of orange juice, one 8-ounce cup of coffee, 3 cups of water, and 1 cup of tea. This patient has a total intake of _________ mL over the 12-hour period. --correct answer--2520 The nurse is beginning an assessment of a patient suspected of being in shock. What should the nurse do first? --correct answer--Determine if the airway is patent. The nurse is assisting with the assessment of a patient undergoing chemotherapy with doxorubicin. Which side effect(s) should the nurse observe? Select all that apply. --correct answer--Alopecia Red urine Cardiac damage Nausea and vomiting An older patient with a fulminating foot wound is entering the late phase of septic shock. Which actions should the nurse take to support the patient at this time? Select all that apply. --correct answer--Provide meticulous skin care. Provide oxygen via face mask as prescribed. Administer IV antibiotics as prescribed. Monitor infusion of prescribed IV fluids. The adult daughter of a skilled facility resident is concerned because the patient is becoming increasingly irritable and nasty to the daughter and care providers. What should the nurse suspect is occuring with the patient? --correct answer--An infection The nurse is preparing to provide acetaminophen (Tylenol) as needed to the following patients. For which patient should the nurse question the order? - -correct answer--A 38-year-old with history of alcoholism When preparing to witness the signing of the consent form, the patient starts asking many questions about the surgery and its possible complications. What action should the nurse take? --correct answer--Have the physician answer the patient's questions before consent signing. The nurse is providing care for a patient returning from knee replacement surgery who is taking maintenance doses of methadone related to a history of drug abuse. Postoperative orders include Tylenol with codeine, 2 tablets every 4 hours as needed for pain, and methadone, 5 mg every 6 hours. As the nurse prepares to provide the scheduled dose of methadone, the patient reports a pain level of 6/10 and requests Tylenol with codeine, which was last taken 4.5 hours ago. Which action by the nurse is best? --correct answer--Give the methadone and the Tylenol with codeine. While reviewing laboratory results the nurse suspects that a patient receiving chemotherapy for cancer has reached the nadir. What action(s) should the nurse take at this time? Select all that apply. --correct answer--Maximize infection control practices. Closely examine the skin and mucous membranes for bleeding. A patient diagnosed with hypovolemic shock has an estimated blood loss of 500 mL, 250 mL of emesis, and 250 mL of insensible water losses. The health care provider prescribes the patient to receive 3 mL of 0.9% normal saline via IV infusion to replace each mL of fluid loss to be infused over 24 hours. How many mL of the fluid should the patient receive each hour? Calculate to the nearest whole number. --correct answer--125 A student nurse is observing surgery in which a general anesthetic is being administered. After the intravenous (IV) induction agent is given, what action should the nurse anticipate the anesthesia provider will take next? -- correct answer--Use an endotracheal tube to intubate the patient. A patient is prescribed a dose of ondansetron (Zofran) before surgery. What should the nurse explain to the patient about the purpose of this medication? --correct answer--Reduces emesis The patient is scheduled for a surgical procedure where a permanent artificial opening is going to be made. Which suffix should the nurse use when documenting this patient's surgery? --correct answer---ostomy The nurse is explaining cancer to a group of community members. Which should the nurse use as the best definition of cancer? --correct answer--A cluster of disorganized cells that grow out of control A patient is having procedural sedation and analgesia for a short surgical procedure. How often should the nurse monitor the patient's vital signs? -- correct answer--Every 5 minutes A patient receiving amifostine (Ethyol) as a cytoprotectant asks, "Is that the medication that prevents vomiting?" What should the nurse respond to the patient? --correct answer--"No, this medication is given to prevent kidney damage by the chemotherapy agents."